ProfessorCrispian Scully CBE, MD, PhD, MDS, MRCS, FDSRCS, FDSRCPS, FFDRCSI, FDSRCSE, FRCPath, FMedSci, FHEA, FUCL, FBS, DSc, DChD, DMed (HC), Dr (hc), in Scully's Medical Problems in Dentistry (Seventh Edition), 2014
Recognition of the alcoholic is notoriously difficult and the history unreliable. Findings that suggest alcoholism may arise from the social or medical history (Table 34.18). The CAGE questionnaire may be helpful and a positive response to any of the following questions suggests a diagnosis of alcoholism:■
Have you ever felt the need to cut down on drink?■
Have you ever felt annoyed by criticism of your drinking?■
Have you ever felt guilty about drinking?■
Do you drink a morning eye opener?
Two or more affirmative answers indicate probable alcoholism. A five-shot questionnaire suggests alcoholism if it produces scores over 5 (Table 34.19). The NHS has a useful questionnaire (Appendix 34.2).
Signs may include discovery of used bottles at home, at work or elsewhere. Signs or symptoms of chronic excessive alcohol intake include: slurred speech; alcohol on the breath; self-neglect (whether of the mouth or shabbiness of clothes); an evasive, truculent, over-boisterous or facetious manner; indigestion (particularly heartburn); anxiety (often with insomnia); or tremor. Later signs or symptoms include palpitations and tachycardia, cardiomyopathy and signs of malnutrition.
Blood investigations that may be diagnostically helpful may detect macrocytosis, raised levels of alcohol, gamma-glutamyl transpeptidase (gamma-GT or GGT) and other hepatic enzymes, levels above 1.3% of carbohydrate-deficient transferrin isoforms (% CDT), and folate deficiency of no obvious cause.
Treatment of alcoholism is by encouraging the patient to drink in a less damaging way and to accept help to deal with the crises and the physical, behavioural and social damage that result, or to learn to abstain from alcohol. Admission to manage rehabilitation and ensure abstinence, nutritional replacement of thiamine and folate, and drugs that reduce dependence (naltrexone, acamprosate or clomethiazole) or that cause unpleasant side-effects if alcohol is taken (disulfiram [Antabuse]) may help.
If the alcohol supply is reduced or cut off, or if blood alcohol levels fall sharply, the abstinence or alcohol withdrawal syndrome (AWS) may appear, with morning ‘shakes’ – typically trembling of the hands but possibly involving the whole body. Morning nausea and vomiting are sometimes called ‘toothbrush heaves’. Other withdrawal symptoms are diarrhoea, sweating, rapid pulse and raised blood pressure, confusion, agitation, fits, illusions, misperceptions, hallucinations or delusions. The full-blown syndrome is called ‘delirium tremens’ or ‘DTs’. The whole withdrawal syndrome lasts about a week and requires medical supervision and use of benzodiazepines or clomethiazole.